Ovarian Cancer Stage IV

Stage 4 ovarian cancer is the most advanced form of the disease, where cancer cells have spread beyond the ovaries and abdomen to distant parts of the body such as the liver, lungs, or other organs. While this is a serious diagnosis, treatment options exist to help control the cancer, extend life, and improve quality of life.

Table of contents

• What is stage 4 ovarian cancer?
• Signs and symptoms
• Treatment approaches
• Survival and prognosis
• Living with advanced ovarian cancer

What is stage 4 ovarian cancer?

Stage 4 ovarian cancer means the cancer has spread to distant parts of your body, far from where it started in the ovaries. This is the most advanced stage of ovarian cancer^[1]. Doctors determine the stage of your cancer using information from tests, scans, and samples taken during surgery^[3].

The term “metastasis” describes cancer that has spread to other parts of the body. In stage 4 ovarian cancer, the disease has moved beyond the pelvis and abdominal cavity to organs such as the liver, lungs, or bones^[6].

Doctors divide stage 4 ovarian cancer into two groups^[1]:

• Stage 4a: The cancer has caused fluid to build up in the lining around the lungs. This fluid buildup is called a malignant pleural effusion, and it contains cancer cells^[2].
• Stage 4b: The cancer has spread to the inside of the liver or spleen, lymph nodes outside the abdomen, or other organs such as the lungs^[1].

The staging system used for ovarian cancer also applies to cancers of the fallopian tubes and a condition called primary peritoneal cancer. These cancers start in similar types of tissue and are treated in comparable ways^[3].

Signs and symptoms

Ovarian cancer often doesn’t cause noticeable symptoms in the early stages, which is why many cases aren’t diagnosed until later stages^[2]. One way to tell if symptoms might be related to ovarian cancer is that they persist over time or get worse, rather than going away^[2].

Common symptoms of stage 4 ovarian cancer include^[2][8]:

• Feeling full even after eating only a small amount
• Weight loss without trying
• Digestive problems such as constipation or diarrhea
• Pain and bloating in the belly area
• Vomiting
• Needing to urinate frequently
• Tiredness
• Lower back pain
• Shortness of breath

Because these symptoms can also be caused by other common conditions, they may not immediately raise concern about cancer. However, if you experience these symptoms persistently, you should schedule a visit with a healthcare provider^[5].

Treatment approaches

The main goal of treating stage 4 ovarian cancer is to control the disease for as long as possible, which can help you live longer and feel better^[2]. Your healthcare team will consider several factors when recommending treatment, including where the cancer has spread, whether a specialist surgeon believes they can remove all visible cancer, and your overall health^[1].

Surgery

Surgery plays an important role in treating stage 4 ovarian cancer. The specialist surgeon, called a gynaecological oncologist, will aim to remove as much cancer as possible. This type of surgery is called cytoreductive surgery or debulking surgery^[1].

During surgery, the surgeon typically removes^[1]:

• Both ovaries
• Both fallopian tubes
• Your womb, including the cervix

The surgeon will also check where the cancer has spread in your pelvis and whether it is in your lymph nodes. They may remove parts of other organs if cancer has spread there, such as sections of the intestines, liver, or bladder^[2].

In some cases, surgery might not be possible if the cancer has spread too widely or if you are not well enough to undergo the procedure^[1].

Chemotherapy

Chemotherapy uses drugs to destroy cancer cells. For stage 4 ovarian cancer, you might receive chemotherapy at different times in relation to surgery^[1]:

• Adjuvant chemotherapy: Given after surgery to destroy cancer cells that remain
• Neoadjuvant chemotherapy: Given before surgery to shrink the tumor, making surgery easier, followed by additional chemotherapy after surgery
• Hyperthermic intraperitoneal chemotherapy (HIPEC): Chemotherapy delivered directly into the abdomen during surgery

The most common chemotherapy combination for ovarian cancer includes a platinum drug such as carboplatin or cisplatin, combined with a taxane drug such as paclitaxel or docetaxel^[13].

If surgery is not possible, you may receive chemotherapy on its own to shrink the cancer as much as possible and slow its growth^[1].

Targeted cancer drugs

Some people may receive treatment with a targeted cancer drug. These drugs work differently from chemotherapy by targeting specific features of cancer cells^[1].

You might have a targeted cancer drug^[1]:

• Together with chemotherapy
• On its own
• After chemotherapy is finished

PARP inhibitors are a type of targeted drug that may be given to patients after chemotherapy, especially if genetic testing reveals a BRCA mutation. These medications are typically given for about two years to help keep the cancer from returning^[20].

Other treatments

You might receive other treatments to help relieve symptoms. These could include treatment for fluid buildup in the abdomen (called ascites), treatment for a blocked bowel, or radiotherapy to relieve symptoms like pain^[1].

Survival and prognosis

The five-year relative survival rate compares how likely someone with a specific type and stage of cancer is to survive for five years compared to people without that cancer^[2].

For stage 4 ovarian cancer, survival rates depend on the type of ovarian cancer^[2]:

• For germ cell tumors of the ovary: 71%
• For ovarian stromal tumors: 70%
• For invasive epithelial ovarian cancer: approximately 30%

These survival rates are based on people diagnosed between 2012 and 2018, and rates may improve as better treatments become available^[2].

Your individual outlook depends on many factors specific to you, including your age, overall health, how well your cancer responds to treatment, and what treatment options are available^[2][24]. Some people with stage 4 ovarian cancer have lived for many years with the disease, and about 20% of those with late-stage ovarian cancer survive more than 12 years after treatment^[24].

It’s important to remember that survival statistics are averages and do not predict what will happen in your individual case. Your doctor can provide an estimate based on your specific situation^[8].

Living with advanced ovarian cancer

Managing side effects

Treatment for ovarian cancer can cause both short-term and long-term side effects. Short-term side effects of chemotherapy may include muscle and joint aches, weak legs, peripheral neuropathy (numbness and tingling in fingers and toes), nausea, vomiting, fatigue, and lack of appetite^[20].

Some side effects can become long-term or permanent. For example, peripheral neuropathy may last for months or become permanent, and it can take a full year to recover your typical energy level after chemotherapy^[20].

Bowel issues are common because ovarian cancer often affects the bowels. You may experience diarrhea, constipation, or in serious cases, bowel obstruction. Your healthcare team can help you manage these symptoms with medications and personalized treatment plans^[20].

Follow-up care

After completing treatment, you will likely be asked to schedule frequent follow-up visits with your gynecologic oncologist. During these visits, your doctor may ask questions about your general health and recommend examinations or scans to screen for signs of returning cancer or treatment side effects^[22].

Follow-up appointments typically occur every 2 to 4 months for the first few years after treatment, then every 3 to 6 months to watch for recurrence and screen for other types of cancer^[22][23].

Emotional and practical considerations

Living with advanced cancer brings emotional and practical challenges. It’s normal to experience a range of emotions including disbelief, anger, fear, or depression. Some people view this time as an opportunity to reflect, while others struggle with the reality of the diagnosis^[21].

Having conversations with loved ones about your wishes for future care can be difficult but helpful. This might include discussions about advance directives, memorial plans, and your will^[21].

Many people find it helpful to connect with others who understand what they’re going through. Support groups and connecting with other patients can remind you that you’re not alone^[21].

Coping with fear of recurrence

Ovarian cancer has a high recurrence rate, and worrying about the cancer returning is a common concern. Talking openly with your healthcare team about this fear and understanding the signs to watch for can help you feel more in control^[20].

Palliative care

Even when treatment is ongoing, you may benefit from palliative care. This type of care focuses on relieving symptoms and improving quality of life, rather than curing the disease. Palliative treatments can help manage pain, digestive issues, and other symptoms^[24].

As the disease progresses and treatment options become less beneficial, your care goals may shift entirely to comfort and symptom management^[21].